In 1990 Congress became concerned about the quality of care in American nursing homes. The Department of Health and Human Services was directed to prepare a report on nursing homes by the beginning of 1992. Last week DHHS finally sent the first part of that report to Congress a little over eight years late. Maybe it took so long because the figures on nursing home care are so bad.

Nursing home operators and patient advocates tend to disagree on many things, but central to their differences is the appropriate level of staffing required to operate safe and healthy nursing homes. The DHHS report to Congress attempts to determine minimum and optimal staffing levels in nursing homes.

DHHS reviewers tried three different methods to determine the appropriate staff-patient ratios for nursing homes. They considered the numbers proposed in professional journal articles. They also considered “outcome” measures like injury and death rates, and compared them to staff ratios.

Finally, the reviewers conducted “time-motion” studies in an attempt to determine how many staff hours are required to adequately care for each nursing home resident. While the literature review was not very helpful, the other two measures provided strong arguments for a minimum staffing level.

The report proposes a minimum staffing level of 2.0 hours of aides for each resident day. In other words, one full-time aide position should be filled for every four patients in the facility.

According to the report, there should also be one full-time RN on staff for every 40 residents, and a combination of RNs and LPNs at the level of about one for every ten patients. Of course, those staff members need to be spread across shifts to provide 24-hour coverage as necessary.

How do nursing homes stack up against those minimum requirements? Poorly, as it turns out. More than half (54%) of nursing homes studied now fall below the minimum staffing level for aides, and about a third fall below the minimum standards for professional staff. That is for minimum standards: the figures are much bleaker when compared to optimum levels.

According to DHHS it would be much better if RN and LPN rates were considerably higher. The agency recommends that RNs should be hired at the rate of one for every 18 residents, and the combination of RNs and LPNs should total one for every 8 patients. Between half and two-thirds of all nursing homes fall below those preferred staffing levels.

Why are staffing levels so low? One culprit is the federal government itself. Vigorous budget-cutting by Congress has resulted in a record rate of bankruptcies in the industry. More on that problem, and the early Republican response to the report, in next week’s Issues.